Comparison of cefoperazone and mezlocillin with imipenem as empiric therapy in febrile neutropenic cancer patients

Cefoperazone/Sulbactam-Induced Abdominal Wall Hematoma and Upper Gastrointestinal Bleeding: A Case Report and Review of the Literature

An 87-year-old woman developed abdominal wall hematoma and upper gastrointestinal bleeding during treatment with cefoperazone/sulbactam for pneumonia. The woman received cefoperazone/sulbactam at 4.5 g twice daily for intravenous infusion. After 7 days, she developed sudden onset of left lower abdominal pain, associated with subcutaneous mass, and vomited a coffee-colored liquid. Investigations revealed a coagulation index abnormality and activated partial thromboplastin time and prothrombin time increased obviously. She was diagnosed with cefoperazone-induced hemorrhage. Cefoperazone/sulbactam was discontinued and the patient received vitamin K1. The blood coagulation function improved and hematoma disappeared after 3 days. A Naranjo assessment score of 6 was obtained, indicating a probable relationship between the patient’s coagulation function disorder and her use of the suspect drug.

Profile of infections and outcome in high-risk febrile neutropenia: experience from a tertiary care cancer center in India

Objective of the present study was to describe the profile of infections in febrile neutropenia (FN) in acute leukemia and hematopoietic stem cell transplant (HSCT) with emphasis on response to therapy and outcome. In a prospective, observational single-institutional study, consecutive episodes of high-risk FN were enrolled over a 1½-year period. Uniform antibiotic policy and response criteria were used. Of the 200 episodes enrolled, acute leukemia induction comprised 40.5%, consolidation with high-dose cytarabine 22.5%, HSCT 29% (auto-HSCT 84%), and others 8% of the episodes, respectively. Microbiologically documented infections comprised 30% episodes, while bacteremia was documented in 26% episodes. Gram-negative isolates were more common (55.7%). Cefoperazone-sulbactam had the highest in vitro efficacy against Gram-negative rods. Carbapenem resistance was most prevalent among Acinetobacter spp. (80%) and Pseudomonas aeruginosa (50%). All Gram-positive cocci other than enterococci were susceptible to vancomycin, while 2/8 enterococci were resistant to it. Cefoperazone-sulbactam and amikacin were used as first-line antibiotics. Overall mortality was 8%. On multivariate analysis, mortality was associated with a nadir leukocyte count < 200/μl and an abnormal chest radiograph. Among high-risk FN patients, inspite of a high-level of resistance to antibiotics, a frontline regime containing cefoperazone-sulbactam could restrict the use of imipenem and resulted in an acceptable mortality of 8%.

Evaluation of imipenem 1.5 g daily in febrile patients with short duration neutropenia after chemotherapy for non-leukemic hematologic malignancies and solid tumors: personal experience and review of the literature

Numerous studies have demonstrated efficacy of imipenem-cilastatin, 50 mg/kg/day, as first line therapy in febrile patients with neutropenia of short duration consecutive to cytostatic chemotherapy. However, only two studies used low dosage of this antibiotic as 1.5 g/day, in prospective, double blind, randomized clinical trials, in this indication. Efficacy and tolerability of imipenem-cilastatin 0.5 g three times daily IV in 30-min infusions, as first-line empiric therapy, were retrospectively evaluated in our hematological unit. From January 1996 to September 2000, 30 neutropenic patients (12 females) with 45 febrile episodes were included. Median age was 57.5 years (31-75). Twenty-four of them had lymphomas, 4 solid tumors and 2 myelomas. There were 13 clinically documented infections, (CD, 28.8%), 16 microbiologically documented infections, (MD, 35.6%) and 16 febrile episodes corresponding to fever of unknown origin, (FUO, 35.6%). The median neutrophils count on nadir (n = 44), was 67/mm3 (8-369). The median duration of neutropenia was 5 days (3-15). Bacteremia was observed in 10 patients, urinary tract infection in 3 patients. The most frequently isolated microorganism was Escherichia coli. The overall success rate of the first line therapy was 66.7%. Adverse events were observed in 11.1% of the patients without necessity to stop treatment. The MD infections showed a lower rate of success compared with CD infections and FUO. These data were in accordance with the previous studies. The importance of number of microorganisms (p = 0.007) and of infected sites (p = 0.01) appeared as prognostic factors (univariate analysis). Although imipenem-cilastatin has been used in numerous studies as empiric broad-spectrum antibiotic therapy in the treatment of febrile neutropenic cancer patients, the exact dosage of this antibiotic is still not standardized. However, utilization of this antibiotic in monotherapy at low dosage seems to us to be safe and effective as usual dosage in the antimicrobial treatment ofthe febrile patients with post chemotherapy neutropenia of short duration.

Carbapenems and monobactams: imipenem, meropenem, and aztreonam

Imipenem and meropenem, members of the carbapenem class of beta-lactam antibiotics, are among the most broadly active antibiotics available for systemic use in humans. They are active against streptococci, methicillin-sensitive staphylococci, Neisseria, Haemophilus, anaerobes, and the common aerobic gram-negative nosocomial pathogens including Pseudomonas. Resistance to imipenem and meropenem may emerge during treatment of P. aeruginosa infections, as has occurred with other beta-lactam agents; Stenotrophomonas maltophilia is typically resistant to both imipenem and meropenem. Like the penicillins, the carbapenems have inhibitory activity against enterococci. In general, the in vitro activity of imipenem against aerobic gram-positive cocci is somewhat greater than that of meropenem, whereas the in vitro activity of meropenem against aerobic gram-negative bacilli is somewhat greater than that of imipenem. Daily dosages may range from 0.5 to 1 g every 6 to 8 hours in patients with normal renal function; the daily dose of meropenem, however, can be safely increased to 6 g. Infusion-related nausea and vomiting, as well as seizures, which have been the main toxic effects of imipenem, occur no more frequently during treatment with meropenem than during treatment with other beta-lactam antibiotics. The carbapenems should be considered for treatment of mixed bacterial infections and aerobic gram-negative bacteria that are not susceptible to other beta-lactam agents. Indiscriminate use of these drugs will promote resistance to them. Aztreonam, the first marketed monobactam, has activity against most aerobic gram-negative bacilli including P. aeruginosa. The drug is not nephrotoxic, is weakly immunogenic, and has not been associated with disorders of coagulation. Aztreonam may be administered intramuscularly or intravenously; the primary route of elimination is urinary excretion. In patients with normal renal function, the recommended dosing interval is every 8 hours. Patients with renal impairment require dosage adjustment. Aztreonam is used primarily as an alternative to aminoglycosides and for the treatment of aerobic gram-negative infections. It is often used in combination therapy for mixed aerobic and anaerobic infections. Approved indications for its use include infections of the urinary tract or lower respiratory tract, intra-abdominal and gynecologic infections, septicemia, and cutaneous infections caused by susceptible organisms. Concurrent initial therapy with other antimicrobial agents is recommended before the causative organism has been determined in patients who are seriously ill or at risk for gram-positive or anaerobic infection.

Cost-effectiveness of ceftazidime or imipenem/cilastatin versus ceftriaxone + aminoglycoside in the treatment of febrile episodes in neutropenic cancer patients in Germany

A three-pronged cost-effectiveness analysis of the treatment of febrile episodes in neutropenic cancer patients was conducted. It included a review of 37 randomized, controlled studies in the MEDLINE and EMBASE databases (1980-1996). Clinical outcomes as well as costs of treatment with imipenem/cilastatin, ceftazidime and ceftriaxone + aminoglycoside were compared. Primary therapy and modification, respectively, were successful in 62 and 27% of patients treated with imipenem/cilastatin, in 56 and 31% with ceftazidime and in 41 and 13% with ceftriaxone + aminoglycoside. From the perspective of a 1,800-bed teaching hospital, the average overall cost per successfully treated patient was DM 7,475 with imipenem/cilastatin, DM 7,810 with ceftazidime and DM 8,963 with ceftriaxone + netilmicin (DM 1 = USD 0.56; 7/97). The costs for the German national economy were imipenem/cilastatin DM 23,828, ceftazidime DM 24,985 and ceftriaxone + netilmicin DM 29,838.

Imipenem or cefoperazone-sulbactam combined with vancomycin for therapy of presumed or proven infection in neutropenic cancer patients

The purpose of this prospective randomized study was to compare the efficacy and safety of imipenem and cefoperazone-sulbactam combined with vancomycin for the treatment of fever in neutropenic cancer patients. Patients were assigned to either imipenem 500 mg/m2 (500 mg for bone marrow transplant recipients) every 6 h or cefoperazone (2 g)-sulbactam (1 g) every 8 h All patients received vancomycin 1 g every 12 h. A total of 457 febrile or infectious episodes occurring in 407 patients were entered in the study. The response rate was 73% for imipenem plus vancomycin and 74% for cefoperazone-sulbactam plus vancomycin among the 369 episodes that could be evaluated. Response rates were comparable for the two regimens with regard to infecting organism, administration of antimicrobial prophylaxis, and neutrophil count and trend. The frequency of side-effects was significantly higher for imipenem plus vancomycin (11% vs.5%, p = 0.02), due to therapy-associated nausea and vomiting (5.3% vs. 0%, p = 0.0004). The overall frequency of superinfections was similar with both regimens, but Clostridium difficile colitis occurred significantly more often in patients receiving imipenem plus vancomycin (5 vs. 0, p = 0.02). In this study cefoperazone-sulbactam plus vancomycin was an effective alternative to imipenem plus vancomycin for initial therapy of fever in neutropenic patients.

Infections in neutropenic patients. II: Management

Improvement in supportive care including the introduction of new antibiotics, antiviral and antifungal agents and haematopoietic growth factors have all contributed to a decreased chemotherapy-related mortality and morbidity in cancer patients. However, infection during neutropenia is still a major complication and a great concern for the clinician responsible for the patient. Management of infectious complications in the neutropenic patient is reviewed.

Imipenem/cilastatin: an update of its antibacterial activity, pharmacokinetics and therapeutic efficacy in the treatment of serious infections

The prototype carbapenem antibacterial agent imipenem has a very broad spectrum of antibacterial activity, encompassing most Gram-negative and Gram-positive aerobes and anaerobes, including most beta-lactamase-producing species. It is coadministered with a renal dehydropeptidase inhibitor, cilastatin, in order to prevent its renal metabolism in clinical use. Extensive clinical experience gained with imipenem/cilastatin has shown it to provide effective monotherapy for septicaemia, neutropenic fever, and intra-abdominal, lower respiratory tract, genitourinary, gynaecological, skin and soft tissues, and bone and joint infections. In these indications, imipenem/cilastatin generally exhibits similar efficacy to broad-spectrum cephalosporins and other carbapenems and is at least equivalent to standard aminoglycoside-based and other combination regimens. Imipenem/cilastatin is generally well tolerated by adults and children, with local injection site events, gastrointestinal disturbances and dermatological reactions being the most common adverse events. Seizures have also been reported, occurring mostly in patients with impaired renal function or CNS pathology, or with excessive dosage. Although it is no longer a unique compound, as newer carbapenems such as meropenem are becoming available, imipenem/cilastatin nevertheless remains an important agent with established efficacy as monotherapy for moderate to severe bacterial infections. Its particular niche is in treating infections known or suspected to be caused by multiresistant pathogens.

Current Approach to the Management of Neutropenia

Neutrophils have a critical role in host defense. Reduction in the absolute neutrophil count to below 1,000/μL is associated with increased susceptibility to infection. The pattern of infections depends on the severity and the duration of neutropenia and other associated defects in host defense mechanisms and exposure to antibiotics and other drugs, particularly corticosteroids and immunosuppressive agents. Breaks in the integrity of the skin or the gastrointestinal mucosal surfaces serve as the portals of entry for the majority of infecting organisms. Empiric antibiotic therapy and hospitalization are almost always required for the management of fever (temperature >38.2°C) in a neutropenic patient. A single antibiotic (e.g., ceftazidime or imipenem) or a combination of antibiotics with activity against both gram-positive and gram-negative organisms usually provides effective antimicrobial therapy. In low-risk patients, trials of out-patient therapy are ongoing. When febrile neutropenia does not respond to empiric broad-spectrum antibacterial therapy, fungal infections, particularly Candida and Aspergillus, should be considered, and antifungal therapy should be initiated. Recently, availability of the hematopoietic growth factors, particularly G-CSF and GM-CSF, have changed the approach to prevention and treatment of neutropenia. Randomized controlled studies have established that these growth factors accelerate hematopoietic recovery following chemotherapy and bone marrow transplantation. By shortening the duration of neutropenia, many of the heretofore inevitable problems with fever and infection can be avoided. The only major factor limiting the use of these agents is their cost. Despite the use of these growth factors, some patients will still experience slow hematopoietic recovery. For these patients, use of neutrophil transfusions, possibly from G-CSF-stimulated normal donors, may prove to be a useful adjunctive therapy.

Imipenem versus gentamicin combined with either cefuroxime or cephalothin as initial therapy for febrile neutropenic patients

A prospective randomized study was conducted to determine the efficacy of imipenem-cilastatin (hereafter referred to as imipenem) (500 mg four times daily) versus combination therapy for febrile neutropenic patients receiving either no prophylaxis or ciprofloxacin for prevention of infections. Combination therapy consisted of gentamicin (80 mg every 8 h) plus either cefuroxime (1,500 mg every 8 h) or cephalothin (1,000 mg every 4 h) for suspected catheter-related infections. Ninety-four neutropenic fever episodes in 87 patients were evaluable for efficacy. The overall clinical rate of response to imipenem was significantly higher than that to combination therapy (91 versus 74%; P = 0.05). The difference in efficacy was most pronounced in patients with microbiologically documented infections (89 versus 53%; P = 0.025), which were predominantly caused by gram-positive bacteria. Differences in susceptibility may have caused the better rate of response to imipenem. Two of 29 gram-positive bacteria were imipenem resistant, whereas 10 were resistant to cephalothin and cefuroxime and 12 were resistant to gentamicin. No causative gram-negative bacterium and 24 gram-positive bacteria were isolated in 61 fever episodes with ciprofloxacin prophylaxis (oral). In contrast, nine causative gram-negative and five gram-positive bacteria were isolated in 33 episodes without prophylaxis. The difference in distribution proved to be statistically significant for gram-negative (P = 0.0001) as well as gram-positive (P = 0.025) bacteria, indicating that ciprofloxacin effectively prevented the occurrence of gram-negative bacteria and may have contributed to the relatively large number of gram-positive bacteria isolated. Empirical initial therapy with imipenem may be a valuable alternative to combination therapy for neutropenic fever episodes.

Non-nephrotoxic empiric antimicrobial therapy in febrile neutropenic cancer patients

We evaluated the efficacy of piperacillin-pefloxacin as a non-nephrotoxic antibiotic combination in febrile neutropenic cancer patients treated with nephrotoxic chemotherapy. 40 patients: 34 with solid tumours and 6 with non-Hodgkin lymphoma, were treated during 55 episodes with: piperacillin 4 g intravenously every 8 h and pefloxacin 400 mg intravenously every 12 h. If the patient remained febrile after 72 h, 1 g vancomycin intravenously was added every 12 h. The mean duration of neutropenia was 7 days (range 3-13). Infection was microbiologically documented in 13 episodes (8 gram-positive cocci and 7 gram-negative bacilli). Temperature became normal in 38 patients with piperacillin-pefloxacin and 12 further episodes were resolved by the addition of vancomycin. 2 patients had an early change of antibiotics because of clinical deterioration, there were 2 protocol violations and 1 patient's temperature became normal after the addition of amphotericin. Neither septic death nor toxicity were observed. We conclude that this empirical treatment is active and safe and warrants further comparative trials.

Imipenem-cilastatin for empirical therapy in neutropenic patients with fever: an open study in patients with hematologic malignancies

In adult neutropenic patients with hematological malignancies, we explored imipenem-cilastatin as empirical antibiotic therapy in a dose of 500 mg four times daily. Changing to second-line treatment was only resorted to if clinical deterioration, new infections or recurrence of fever occurred. A clinically or microbiologically documented infection was apparent in 115 of 150 episodes studied (76.7%). Imipenem-cilastatin was successful in 70.7% of all episodes and in 67.8% of all proven infections. Modification was necessary and successful in 22.0% of all episodes. 11 patients died while still febrile, 6 of them by infection (4%) and 5 because of progressive disease (3.3%). Imipenem-cilastatin is safe initial therapy in neutropenic febrile patients.

Empiric Antimicrobial Therapy in the Febrile Granulocytopenic Patient

In the normal individual, about 100 billion polymorphonuclear leukocytes (neutrophils) enter the bloodstream daily from the bone marrow. About half of the intravascular neutrophils are adherent (marginated) to the endothelium of small vessels and the remainder are circulating. Without unusual disturbances, the half-life of the intravascular neutrophil is about six hours. Although the number of circulating neutrophils seems enormous, it represents only 5% of the total body content of these cells, the major portion residing in the bone marrow.

It is remarkable that quantitation of polymorphonuclear leukocytes in a drop of peripheral blood can be highly predictive of an individual's resistance and response to infectious diseases, especially those caused by bacteria. Neutrophil activity is complex and its role in host defense is dependent upon factors other than quantity. Nevertheless, when the absolute neutrophil count is maintained at values less than 1000/cu mm, increased susceptibility to infection occurs and is at a rate that is inversely proportional to the neutrophil count. When the count is decreased to values of 500 neutrophils/cu mm or less, the frequency of serious bacterial infection reaches a point where special attention must be directed to the patient at the earliest sign of infection.

Infectious disease management of adult leukemic patients undergoing chemotherapy: 1982 to 1986 experience at Stanford University Hospital

PURPOSE

The purpose of this study was to determine the recent incidence of infection and to evaluate antimicrobial usage among adult leukemic patients undergoing chemotherapy for acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL) at Stanford University Hospital.

PATIENTS AND METHODS

The records of 142 adult patients from a consecutive series of 226 induction or consolidation/maintenance chemotherapy courses for AML or ALL between 1982 to 1986 were reviewed retrospectively. Data were analyzed to compare the infectious disease complications and antimicrobial usage for patients receiving identical chemotherapy for a specific phase of leukemia treatment. Evaluation for each chemotherapy course included assessments for the following: compliance with criteria for initiating antibiotics, incidence of infection that was documented by culture or clinical criteria, predictive value of surveillance cultures, incidence of superinfection, survival outcomes, antimicrobial usage, antibiotic-related adverse effects, and cost for antibiotics and diagnostic studies.

RESULTS

Antimicrobials were employed in 190 (84%) of 226 chemotherapy courses. Broad-spectrum antibiotics were regularly begun within the first five days of admission and they were continued for an average of 3.5 weeks until the granulocyte count was greater than 1,000/microL after discontinuation of chemotherapy. There were no differences in the types of infection or outcomes among the patient groups. There was only a 37% rate of documented infections by culture or clinical signs among these patients during their entire hospital stay. Bacterial infections, especially those caused by coagulase-negative staphylococci in patients with Hickman catheters, accounted for 93% of the episodes. Viral and fungal infections accounted for 4% and 3% of documented cases, respectively, and occurred more than 10 days after the institution of broad-spectrum antibiotic therapy. A total of 922 different antimicrobials were employed in 190 courses (average 4.9 per course). The rationale for excessive usage and multiple changes was a persistent or intermittent fever, rather than documented infection(s). This practice led to usage of more broad-spectrum and expensive antibiotics. Further analyses indicate that the greater number of antibiotics employed correlated with apparent increased toxicity, especially renal and hepatic adverse reactions. These toxicities were associated with higher rates of fatal outcomes, i.e., 12 (39%) of 31 patients died with antibiotic-associated hepatic and/or renal insufficiency, compared with 12 (7.5%) of 159 patients who died without antibiotic-associated organ damage.

CONCLUSION

Excessive antibiotic usage and multiple antibiotic changes among adult leukemic patients undergoing chemotherapy appear to increase the risks of adverse hepatic and renal effects and death. Furthermore, this practice leads to use of more broad-spectrum and expensive antibiotics...